The Psychological Consequences of Amputation
Amputation is one of the most severe kinds of bodily injury or medical procedure that a person can undergo. While amputations are rare, they still affect a significant number of people. In the United States, 185,000 people suffer from or undergo an amputation every year. As a result, there are thought to be more than 2 million people currently living with limb loss in the US. Meanwhile, in the UK, the number of annual amputations continues to grow. From 2015 to 2018, there were 27,465 lower-limb amputations performed on UK patients, an increase of 18% compared to the previous three-year period.
Given that amputations cause such severe changes in a person’s bodily appearance and lifestyle, it is not surprising that they are often accompanied by significant psychological effects. In this post, we look at some of the most common causes and consequences of amputation.
The causes of amputation
The most common causes of amputation are surgical procedures and traumatic injuries, but the causes of amputation can also be psychological in nature. Medical researchers have noted that psychiatric conditions such as substance abuse disorders, personality disorders, and mood disorders that precipitate self-harm or suicide can sometimes lead to amputation. In rare instances, people suffering from psychosis or severe intoxication may engage in self-mutilation. In other cases, patients who suffer from chronic pain syndrome can sometimes seek medical amputation in order to alleviate their pain. According to a 1992 review, chronic pain can sometimes induce patients to have multiple, repeated amputations, but as the source of the problem is primarily psychological, this does little to help relieve their pain.
More common than amputations provoked by psychological disorders, though, are those that result from surgical procedures or traumatic accidents. Surgical amputations are carried out when part of a person’s body is so badly affected by infection, tissue damage, or disease that the person’s life is in danger. The injured body part is amputated when there is no other possible option or cure.
By far the most common causes of this kind of medical amputation are chronic vascular disease and diabetes. In fact, in the United States, 82% of medical amputations are performed as a result of diabetes or vascular disease. Unfortunately, however, even when amputations are used to treat diabetes or vascular disease, the chances of survival are not good. Of those who undergo amputation for chronic vascular disease, 60% die within two to five years. Given these bleak prospects, it is understandable that many people awaiting an amputation can suffer severe anxiety or depression. We discuss this in more detail below.
The other most common reason for amputation is traumatic injury. This kind of amputation occurs either when a body part is cut away in an accident (in a workplace injury, for example), or when a body part is so severely damaged by a traumatic event that it has to be removed (as, for example, with limb amputation in cases of severe burn injuries). Most commonly, these kinds of traumatic amputation occur among soldiers as a result of combat injuries. Indeed, a 2006 study reported that during the Iraq war, traumatic amputations were performed on roughly 3,500 soldiers every year. The same study showed that 50% to 70% of all battlefield injuries treated during Operation Iraqi Freedom were injuries to the limbs or extremities.
The psychological effects of amputation
Given the varied causes of amputation and the different contexts in which it may occur, it is unsurprising that it can provoke many different psychological responses in patients. In the vast majority of cases, those responses are negative and damaging.
The first thing to note is that these negative responses can develop even before the amputation takes place. As mentioned, many patients suffering from diabetes or vascular disease will know in advance that they will have to undergo a procedure, causing them to develop anxiety or depression. This can manifest itself either through a generalized response, leading to symptoms like sleep deprivation or social withdrawal, or it can cause patients to become very focused on the fate of their limb. As many patients are aware of the psychological difficulties that they will face after the procedure, their anxiety increases in advance.
After the procedure, the most common psychological responses are intense grief, post-traumatic stress disorder (PTSD), and phantom limb pain. Let’s look at each of these in turn.
Grief
Patients often report experiencing a profound sense of loss following an amputation. They often experience grief for the life they used to lead, and they can sometimes struggle to maintain their sense of self. In some cases, patients can even equate the loss of their limb with the loss of a spouse or loved one. As a result, they may exhibit the five stages of grief, which people often go through when they experience a bereavement. These five stages are as follows:
Denial: This typically occurs during the lead-up to the amputation. It manifests through patients refusing to engage with discussions or ask questions about the procedure. Even after the amputation, patients can remain in denial, refusing to accept that there has been any change in their body or lifestyle. For example, patients may refuse help with tasks that they could previously accomplish independently, like dressing themselves or moving without support.
Anger: This can manifest in numerous different ways. Amputees may be angry at the medical team who performed the amputation. Alternatively, patients may be angry at their family members, themselves, or the general situation they find themselves in.
Bargaining: This involves feeling guilty or questioning whether things could have been done differently. If the amputation has not yet happened, patients may try to bargain by delaying the surgery. Or, after the surgery has taken place, they may try to imagine scenarios in which their limb loss no longer affects them.
Depression: More than just feeling down, depression is a long-term feeling of sadness and hopelessness that can persist for many months or years. As with cases of bereavement, people who suffer amputations can develop depression in response to the loss of their limb.
Acceptance: In this stage, patients come to terms with their new body and learn to adapt to their new way of life. It is hoped that all patients will eventually reach this stage, but it can take many years of rehabilitation and counselling.
PTSD
As outlined in our previous post on complex post-traumatic stress disorder, PTSD can result from any kind of traumatic experience or injury. Its major characteristic is that it causes patients to re-experience their traumatic injury, generally in the form of flashbacks or nightmares. Also, PTSD can cause people to develop patterns of avoidance, in which they try to prevent themselves from being reminded of the traumatic experience. They may avoid contact with the people or places associated with their injury, causing them to become socially withdrawn or reclusive.
As far as PTSD and amputation are concerned, it is unsurprising that PTSD is more common in amputations that result from combat injuries or traumatic accidents. Studies have shown that the rates of PTSD in combat veterans are higher among those who have suffered amputations. Also, residual pain, which is more common in traumatic amputations, can contribute to the development of PTSD. Indeed, a study of patients who continued to experience pain after their amputation found that a quarter of them showed signs of PTSD.
In contrast to amputations that result from traumatic injuries, though, PTSD is much less common in patients who undergo amputation as part of a medical procedure. Studies have found that less than 5% of surgical amputations cause patients to develop PTSD. That said, whenever there are complications with surgery, PTSD is much more common. In these cases, patients can end up blaming the medical team for their condition, making it much more difficult for them to come to terms with the loss of their limb. For further discussion of the psychological consequences of traumatic medical procedures, see our post on the effects of medical negligence.
Phantom limb sensation
Phantom limb sensation, which is the feeling that one’s limb is still present even after it has been removed, is very common among amputees. Mentally and physically, it can take patients some time to adjust to the new reality of their life without a limb. In some instances, patients’ phantom limb sensations are painless, but the percentage of people who experience phantom limb pain may be as high as 85%.
Despite the widespread prevalence of phantom limb pain, its causes and treatment are largely unknown. Researchers have proposed many theories regarding its cause, which range from spontaneous charges of neurons to increased sensitivity during periods of stress. When it comes to treatment, moreover, one problem is that local anesthetics do not always help. This is because the pain is only ambiguously connected with the phantom limb, which is not physically present. Therefore, managing the pain generally requires a combination of psychological and pain-related treatments. This suggests that, for anyone who undergoes an amputation, managing the experience of phantom limb sensation and the pain associated with it is likely to be a stressful and psychologically distressing experience.
Positive responses to amputation
Despite the many difficulties that amputees face, it is important to note that some patients do report having a positive psychological response to their amputation. A study conducted in 2000, which looked at 104 individuals who had suffered traumatic amputations, found that just under half of them (48%) felt that “something good had happened as a result of the amputation.” These individuals reported positive changes in their attitude to life, gratitude for the elimination of pain, and improved coping abilities. While this study cannot be taken as representative for the wide range of people who undergo amputation, it reminds us that people’s psychological responses are always dependent on context and the individual; no one response is guaranteed in any situation.
Summary
As this brief overview makes clear, the psychological consequences of amputation are highly complex. Given the various ways in which amputations can occur, ranging from traumatic combat injuries to long-anticipated surgeries, they can provoke vastly different psychological effects. Nevertheless, the common experience of phantom limb sensation suggests that, at the very least, amputees will require some time to adapt to their new body and lifestyle. While some may eventually see this as a positive opportunity for growth and development, many will find it psychologically challenging. In severe cases, amputees may develop long-term psychological disorders such as depression and PTSD. In summary, therefore, helping people who undergo amputations to come to terms with the experience will require nuanced and multi-layered systems of care that respond to the needs of each individual on a case-by-case basis.
This post is provided for general information purposes and is not intended to cover every aspect of the topics with which it deals. It does not constitute medical, legal, or professional advice, nor is it necessarily an endorsement of the views of Professor Elliott, the U.K. Centre for Medico-Legal Studies, its employees, or its affiliates. Though we aim to ensure that all information is accurate at the time of posting, we make no representations, warranties or guarantees, whether express or implied, that the content in the post is complete or up to date.